What is the management of acute Chronic Obstructive Pulmonary Disease (COPD)?

From the Guidelines

Management of acute Chronic Obstructive Pulmonary Disease (COPD) exacerbations requires prompt intervention with bronchodilators, systemic corticosteroids, and antibiotics when indicated, as outlined in the 2021 clinical practice guideline from the American Academy of Family Physicians 1.

Key Interventions

• Bronchodilation with short-acting beta-agonists (SABAs) like albuterol and short-acting anticholinergics like ipratropium, as recommended by the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1.
• Systemic corticosteroids, typically prednisone 40 mg daily for 5 days, to improve lung function and shorten recovery time.
• Antibiotics, such as amoxicillin-clavulanate, doxycycline, or azithromycin, when there are signs of bacterial infection, to reduce the risk of early relapse and treatment failure.

Additional Considerations

• Supplemental oxygen should be titrated to maintain SpO2 88-92%, avoiding hyperoxia which can worsen hypercapnia.
• Non-invasive ventilation (NIV) should be considered for patients with respiratory acidosis or severe dyspnea with signs of respiratory fatigue, as it improves gas exchange and reduces the need for intubation 1.
• After stabilization, patients should receive a maintenance regimen including long-acting bronchodilators, possibly inhaled corticosteroids, smoking cessation counseling, and pulmonary rehabilitation referral to prevent future exacerbations and improve quality of life.

Prioritizing Morbidity, Mortality, and Quality of Life

The management of acute COPD exacerbations should prioritize reducing morbidity, mortality, and improving quality of life, as outlined in the 2021 clinical practice guideline from the American Academy of Family Physicians 1. This comprehensive approach addresses the acute bronchospasm, inflammation, and potential infection while preventing respiratory failure and setting the stage for long-term management.

From the Research

Management of Acute COPD

The management of acute Chronic Obstructive Pulmonary Disease (COPD) involves various pharmacological and non-pharmacological treatments.

• Pharmacological treatments include:
  • Inhaled bronchodilators, such as beta2 agonists and anticholinergics 2, 3
  • Systemic corticosteroids, which have strong evidence of efficacy in treating exacerbations 4, 5
  • Antibiotics, which are preferred in ICU patients, but lack evidence regarding preferred drugs and optimal duration of treatment for non-ICU patients 4, 2, 3
• Non-pharmacological treatments include:
  • Oxygen therapy, which is essential for hypoxemic patients 2, 3
  • High flow nasal cannulae (HFNC) oxygen therapy, which needs further prospective studies 4
  • Non-invasive mechanical ventilation (NIMV), which is supported by strong evidence of efficacy in patients with hypercapnic acute respiratory failure and respiratory acidosis 4
  • Pulmonary rehabilitation, which is recommended due to its feasibility and safety, especially when associated with standard treatment 4

Treatment Approach

The treatment approach for acute COPD exacerbations involves:

• Increasing the dosage of inhaled short-acting bronchodilators as the first step in outpatient management 3
• Combining ipratropium and albuterol to relieve dyspnea 3
• Using oral corticosteroids, especially for patients with purulent sputum 3
• Considering antibiotics for patients with purulent sputum or inadequate symptom relief with bronchodilators and corticosteroids 2, 3
• Guiding antibiotic choice by local resistance patterns and the patient's recent history of antibiotic use 3

Hospitalized Patients

Hospitalized patients with exacerbations should receive:

• Regular doses of short-acting bronchodilators 3
• Continuous supplemental oxygen 3
• Antibiotics 3
• Systemic corticosteroids 3
• Noninvasive positive pressure ventilation or invasive mechanical ventilation for patients with worsening acidosis or hypoxemia 3